Patient-perceived breakdowns in care are events where something has gone wrong from the perspective of the patient or family member, that could have been prevented, and that has a significant impact on the patient. Conceptually at the confluence of patient safety and patient experience, some patient-perceived breakdowns in care, such as preventable ulcers, meet the standard definition of a medical error, while others, including communication breakdowns, may not. Because patient-perceived breakdowns result in harm - including physical harm, psychological distress, and damage to the patient-physician relationship - they are important targets for improvement. A growing body of research suggests that when patients report their concerns about breakdowns in care, they seldom receive an adequate response. Interventions are urgently needed to improve healthcare systems' and providers' ability and willingness to respond to patient-perceived breakdowns; physicians are critical to such efforts. The reasons that physicians and the systems they work in fail to respond adequately are not known. A thorough understanding of the factors which affect physicians' responses to patient-perceived breakdowns is critical to the development and dissemination of patient-centered interventions to improve the quality and safety of healthcare. Working within the diverse, 10-hospital MedStar Health system, and leveraging pre-existing data from an ongoing AHRQ-funded demonstration project (`Detecting, Addressing and Learning From Patient-Perceived Breakdowns in Care'), the candidate proposes to first conduct an in-depth qualitative analysis of the 1,148 patient interviews already conducted to create a taxonomy of patient-perceived breakdowns in care and associated harms reported by hospitalized patients (Aim 1). Using this taxonomy as a reference, she will interview physicians to understand their perspectives on patient-perceived breakdowns in care, and to identify the factors which influence their willingness and ability to respond to these events (Aim 2). Informed by the interview findings, she will generate testable hypotheses about what factors facilitate or hinder effective responses to patient-perceived breakdowns. In the final phase, the candidate will test these hypotheses by surveying a broad sample of physicians (Aim 3). One section of the questionnaire will contain an embedded experiment to test whether verbatim patient narrative descriptions of patient-perceived breakdowns are more effective than quantitative summaries in influencing physicians' responses. This project will provide a strong foundation for designing and testing an intervention that enables physicians to respond immediately to patient- perceived breakdowns in care, and to participate in system-level responses to prevent recurrence. The candidate, Dr. Kimberly Fisher, is an Assistant Professor of Medicine at the University of Massachusetts Medical School (UMMS), and a practicing pulmonary and critical care physician. Her long-term career goal is to become an independent clinician investigator conducting patient centered outcomes research (PCOR) to address patient-perceived breakdowns in care, and improve the safety, quality, and patient- centeredness of healthcare. She has a unique background with experience implementing quality improvement initiatives, and conducting patient-centered research examining surrogate decision maker's perceptions of care in the intensive care unit. She is currently a member of the research team on the AHRQ-funded demonstration project that provides the context for the research proposed under this K08 award. In the short-term, she seeks additional training to achieve her long-term career goals. She has proposed a training plan that will provide her with skills in advanced qualitative analysis, survey design and analysis, comparative effectiveness research methods, the theory and practice of healthcare safety and quality improvement, and implementation science. She has assembled an exemplary mentorship team and advisory panel. Dr. Kathleen Mazor, PI of the parent grant `Detecting, Addressing, and Learning from Patient-Perceived Breakdowns in Care', will serve as Dr. Fisher's primary mentor and Dr. Thomas Gallagher, co-investigator on the same grant, will serve as secondary mentor. Advisors to Dr. Fisher will include Drs. Peter Lindenauer, Thomas Houston and Judith Ockene. The candidate's institution provides a rich environment which will enhance Dr. Fisher's career development and facilitate completion of the proposed research. Key institutional resources include the Graduate School of Biomedical Sciences at UMMS which provides a scientific community of researchers conducting PCOR and comparative effectiveness research (CER), and offers didactic training in these areas. The Post-doctoral Training in Implementation Science program is a unique opportunity to obtain training and mentorship in the field of Implementation Science, which is critical to the development and evaluation of complex interventions and an important component of CER. The Meyers Primary Care Institute is a joint research endeavor with a focus on population-based research, and CER. The candidate has also garnered full and enthusiastic support for this work from leadership at MedStar Health, which will serve as the clinical setting for the research, as confirmed by Dr. David Mayer, Corporate Vice President for Quality and Safety at MedStar Health . The candidate's career goals and expected findings are consistent with AHRQ's mission to produce evidence to make healthcare safer, higher quality, more accessible, equitable, and affordable, and to...make sure that the evidence is understood and used.